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Derrick Smith, Photo by Derrick Smith.
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Derrick Smith wears many hats, including “Derrick the Gardener.” He promotes health and nutrition through gleaning in urban gardens and area farms (EOR, October 2009). This month, “Nurse Smith” describes the need to improve health for underserved communities through addressing health disparities, especially tackling health care reform for those living east of the Anacostia River.
Health Care Reform from a Nurse’s Perspective
“Health care reform addresses the story of why health care is important. It’s not just about money in the pockets of insurance companies. It’s not just about being denied services. I talk from the perspective of the nurse.” For Smith, nurses are at the frontline of patient care. Smith, a veteran of the US Army who served as a medic, uses war analogies: “I’ve been on this battlefield since I started as a nurse. Health care reform is not about the implementation of health care, but about putting people’s (health care workers, health care administrators and policymakers) attitudes in check.”
To Smith, health care crosses the divides of race, gender, class and politics. “If health care providers were held accountable for not following the rules, there would be fewer problems for patients. The guidelines for quality health care are out there. Health care reform for me takes these guidelines and makes them rules. Health care providers should follow them or lose money.” Medicaid and the HIV/AIDS Administration as insurers often fail to hold health care providers accountable for providing substandard care to the poor and the most vulnerable.
“I’ve got three stories to tell about my adventures as a nurse and health care reform.” These stories include Smith as health educator, HIV case manager, high-risk obstetrics (OB) nurse case manager, and clinical research nurse case manager.
Health Educator
“When I first came to the community, I was a health educator. I worked for a health care system that was implemented once DC General closed. Unlike DC General, they denied services to patients when it interfered with the provider’s faith.
“Sometimes you have to look at a community’s need versus what you understand.” Smith describes a woman who was denied much-needed intervention because the philosophy/mission of the health-care agency was at odds with her needs. “I could not understand why the needs of a 350-pound woman with diabetes for 12 years were not being addressed. I asked, ‘Can she afford a diet for diabetes?’ The amount of money she had beyond food stamps to spend on food was zero. I tried to implement a program showing her how to cook, to shop with what she had. I saw the need to incorporate mental health, which is a big component of obesity and diabetes. These conservatives told me that as a health educator, it was not my responsibility. They said that she had to be motivated to [find resources] on her own.
“I did a prenatal health class. I wrote letters for donations. I contacted the WIC Program to get milk, juice and cold cereal – 100 percent of my prenatal patients were on WIC. I solicited a grocer for one $25 dollar gift card per week [for a four-week prenatal course]. I bought food for the classes with the $25 weekly grocery gift card. I took $10 of my own money to go to Eastern Market to buy produce. The guy was generous and gave me watermelons, grapes, cantaloupes. Other case managers donated things they had so I could make gift bags for each mother.”
Smith noted the irony in his employer’s interference: “As a health educator, they asked me to design a class based on patients’ needs. [The employer] then refused to let me sit with marketing to get a grant for more money. I asked my supervisor if I could get a larger grant to provide prenatal classes for additional community clinics. They said, no. The decision to conduct prenatal classes hinged on clinic management. None were nurses. None were health educators.”
HIV Case Manager
“I became an HIV case manager. I had a caseload of 400. I served four clinics. Four of us served 16 inner-city clinics. The ratio for effective case management according to Health Care Disparities 2008 is one HIV case manager per 75 patients – lower if they are high risk. Almost all our patients were high risk: newly infected, non-compliant with meds.
“I was appalled. How dare they open a brand new clinic and not have enough HIV case managers. We did not need more space, we needed better services.
“A DC guy with HIV had a CD4 count of 2 for five years. He did not take his pills because of bowel problems. He had complications with his organs. I would send him from the clinic to outside referrals, and they would refuse to see him. They would get away with it. I got on my bandwagon with this guy. He was not mentally prepared [to deal with his diagnosis]. He had never seen a psychiatrist. He had a severe learning disability. I called Medicaid to ask them to enforce contracts with these [outside] physicians. I got no response. I contacted the HIV/AIDS Administration, I got no response. I eventually found some wonderful, caring, sincere physicians out there, but there are many physicians who are out for the quick buck.
“I built a relationship with this guy. I had him checked from head to toe. I taught him how to take his pills. Within six months, his CD4 count went from 2 to 46. I saw him a year ago. He looked good. He had filled out. He said, ‘You won’t guess what my CD4 count was.’ It was in the high 400s.
“A woman with HIV was on death’s door. She wanted to change her life. I called a drug rehab center. They said they had no bed for her. I told them they would find a bed for my patient. I told them I was on my way. I took her hand and walked her to the drug rehab center. They met me at the door. They had found her a bed. I saw her a year later. She looked good.
“I tried to do this for all my patients, but you cannot do this with a caseload of 400. Some patients were not from DC. They came from Pennsylvania, New Jersey, Maryland … Since DC was so open, they chose to travel here for care. They did not want those in their states to know they had HIV. They did not want their insurance companies, their employers to know. They were taking DC dollars and services.
“When I left in 2005, I was the only HIV case manager for that organization. There were 16 outpatient clinics that they ran for the city. It was overwhelming.”
High-Risk OB Case Manager and Clinical Research Nurse Case Manager
Smith had more tales about his battles against health disparities. They include the story of a mother whose three children had a chronic, terminal disease. Smith noted that this mother and her children, African-Americans, were disrespected by clinic staff: “I asked the physician to refer the children to mental health. He asked me, ‘Why?’ I said that at ages 15 and 16, they needed to know the ramifications of not complying with their drug protocol. The physician told me that it wasn’t worth it, that it wouldn’t change anything. I was bawling mad. The mother and the teens were in the room when he said that.”
Health Care Reform: ‘The People in It’
“This is why health care reform does not work. It’s not the system, but the people in it.” |
